For many years, the practice of medicine has no longer been shaped solely by science but also by the personal and social needs of the people it serves and the values they hold, especially in obstetrics.1,2 Indeed, women increasingly want to exercise their decision-making autonomy when it comes to planning the modalities of their labour and delivery.3 Conversely, other women have no idea of decision-making autonomy or have no access to it. So, in our time of multicultural societies and increasing migrant subpopulations, obstetric anaesthetists may have to deal with very different and even opposite situations. This is not without any ethical and legal questioning about both the maternal–foetal dyad and the mother's capacity for free and informed decision-making, nor without consequences for anaesthetic management.
The maternal–foetal ecosystem: a unique challenging entity for ethics
Obstetrical ethics need to deal with a particular situation: the maternal–foetal ecosystem, in which two individuals – one existing within the other and with different legal status and representation – can become physically entangled in conflicts of interest, for instance when foetal wellbeing is harmed by maternal choices and circumstances.4
Most national laws in Europe consider the woman and the unborn child as a single entity until the baby is born alive. This somewhat reductionist approach to potential conflicting interests between the foetus and its mother, emphasising only rights-based maternal autonomy, can be a possible cause of ethical – and legal – conflict. According to this approach, the maternal–foetal ecosystem is treated as a single entity, in which maternal autonomy will, in exceptional cases, trump foetal wellbeing.
The opposing view, which considers the foetus as a separate patient, can potentially cause an even bigger ethical and legal controversy, as the maternal human right to bodily integrity and self-determination will be breached if treatment is forced upon the mother, against her wishes, to improve foetal outcome.5
The European Human Rights Act describes the right to life, and although this right does not extend to the intra-uterine foetus, three European Union member states (Slovenia, Hungary and the Republic of Ireland) grant the foetus a constitutional right to life.6 This right to life, though considered a moral right, is not to be confused with legal status, which is only acquired after birth, once the child exists separate from its mother.
However, in clinical practice, the foetus is often considered as a patient, as a result of the development of foetal treatments and intra-uterine surgery.7,8 The unborn child has interests, and the defence of these is the source of what has been called ‘maternal or parental responsibility’ of the pregnant woman.5,9
Some ethical dilemmas, conflicts and challenges
Ethical friction can arise in obstetrics when case-specific circumstances demand that an intervention has to be considered which entails a potential threat to either maternal or foetal wellbeing. This conflict is less pronounced in foetal surgery, in which time is available for proper consideration of the impact of surgery and anaesthesia on maternal and foetal wellbeing, and for a meticulous process of informed consent. But acute major ethical conflict can erupt around the maternal refusal of procedures needed to improve foetal or maternal outcome. In daily practice, cases of rejection of standard treatments, blood transfusion or a possible medically indicated caesarean section are not infrequent.10
In addition, professional frustration may arise when patients demand a caesarean delivery without any medical indication or opt for a risky home birth.11
The weight of the cultural and religious context should not be underestimated. Nor can the father's and sometimes even the family's influence be ignored. As regards the cultural background of the expecting family, the relative importance of the mother's life versus the child's life can be perceived differently, and the freedom of the mother to make an autonomous decision may not be indisputable. So, some cases may become quite challenging and time-consuming.
Free and informed shared decision-making
For years, many controversies have emerged in determining whether the pregnant woman remains free in her decisions with regard to respect of the foetal interests. In most Western countries, the well established principle of self-determination has a heavy moral weight, which is not suspended as a woman is pregnant.5,12,13 Her autonomy is interpreted in terms of respect for personal freedom, value and interests.
However, these interests, when not considered merely experiential, should contain ideals and ideas beyond personal benefit, which are included in a broader normative framework and take into consideration her responsibility and duty to choose what is beneficial for her child as well.
Informed decision-making is the process by which a patient's autonomy can be exercised, demonstrated and legally evaluated. To be a genuine reflection of maternal values, beliefs and freedom of choice, decisions should be made by a person considered free and competent, after carefully balancing all available information on options, risks, benefits and alternatives, and supplied with the proper case-specific facts and recommendations.14
A patient's competence to exercise free decision-making is seldom questioned, but doubt on capacity can arise once diverging preferences between patient and provider surface. A labouring woman, who has a mind-altering focus on delivering and is suffering from pain, anxiety and exhaustion, can be especially vulnerable to this doubt, even if it is demonstrated to be unfounded.15
Free informed consent does not necessarily mean consent without pressure, in obstetrics less than elsewhere. Indeed, the future mother can be under pressure because of the factors set out above. But coercion is unacceptable, be it by selective information provision from professionals or by culturally determined involuntary deferral to spouse, religion or family. Private deliberation between patient and doctor – with adequate independent language translation if needed – remains necessary to establish a patient's free decision.5,16 Proper antenatal education on pain relief and anaesthetic strategies in obstetric emergencies facilitates maternal decision-making during delivery.
A birth plan expressing preferences can be a useful tool but should not be considered a Ulysses contract in which a woman's previous directives have to be respected, even if the overwhelming and unanticipated experience of real pain and suffering changes needs and desires.17 Informed consent is a continuous process. A changed perspective during labour is a sufficient reason to overrule previously made decisions on pain relief or obstetric interventions if circumstances dictate, when in the woman's best interest and not harming the unborn child.
Suggestions for ethical conflict-solving
Many alternative ethical strategies for preventing and solving potential obstetric conflict have been proposed, such as ethics of care, the professional responsibility model and relational consent.14,18,19 In these models, based on mutual respect and trust, the physician's role is not restricted to merely disclosing case-specific medical facts and options. It also provides a rationale, reflection and support in making true self-determined maternal choices, beneficial to both mother and child, throughout the course of care.
To assess in advance and optimise the woman's capacity of decision-making autonomy, a short questionnaire has recently been proposed. It explores the degree of a woman's willingness to be involved in decision-making and the information received and understood, and provides assistance for a true and thorough reflection.20 Antenatal classes can incorporate obstetrical ethics education.
In conflicts related to different cultural backgrounds, a communication strategy sensitive to these differences and aiming at highlighting values and principles which protect and respect the autonomy of the pregnant woman is critical to come to an agreement.5,21 The support of a same-culture doula (birth companion, birth coach or birth supporter) may be of value to achieve this goal.22 Allowing the woman to share her decision capacity with her partner or relatives, within the boundaries of the safeguard of her interests and rights, is important though potentially challenging.5 Several preparatory meetings with the future mother and father may be needed to explain all the ethical issues to come to an agreement on obstetric management, based on the prior shared decision-making process and partnership.23 Pedagogical skills, a structured communication process and an accurate recording of discussions and management plans are strongly advised to avoid conflicts and litigation.24,25
The ultimate goal is to determine together a shared advance-care plan through adaptive counselling. However, directive counselling is sometimes necessary to safeguard the parental obligations if needed.5 Indeed, if physicians are supposed not to impose their own values on their patients, while also facing all the various difficulties encountered, they should always take care not to compromise their professional integrity by accepting choices which are not in line with any reasonable understanding of parental obligations.5,15,26
Last but not least, anaesthetists should acquire a minimal competency in biomedical ethics – including obstetric and multicultural considerations – and the inclusion of bioethics in the medical curriculum should be improved.27,28
To go further
How do we reconcile particular socio-cultural backgrounds and the universal values of medical ethics? A study could be undertaken among European anaesthetists regarding present practice, promotion and respect of the pregnant woman's decision-making autonomy, the difficulties encountered in daily practice and the ways they deal with these ethical conflicts.
Acknowledgements relating to this article
Assistance with the Editorial: none.
Financial support and sponsorship: none.
Conflicts of interest: none.
Comment from the Editor: this Editorial is part of the ‘Anaesthesiology and ethics’ series that is edited by Professor Stefan De Hert. This article was checked and accepted by the Editors, but was not sent for external peer-review.
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